Downloaded from www.ajronline.org by 75.99.193.211 on 11/03/15 from IP address 75.99.193.211. Copyright ARRS. For personal use only; all rights reserved
63
Case Report .
:
.
Intestinal Eglal
Stricture
Shalaby-Rana,1
Martin
Due to Lap-Belt
Eichelberger,2
Benny
Kerzner,3
mural
1 3-year-old
pain,
a band
wall
at the
hospital
girl
wearing
involved
of ecchymosis
level
of the
because
were normal.
of
for 3 weeks.
hepatobiliary
copy,
which
treated. and of
the
present The
showed
and
a passenger
in
the
anterior
was
was
seen
to another
a
occurred,
which
sonog-
scintigraphy, were
abdominal
pain
and an upper
normal.
possible
In addition,
bile reflux
at our
partial obstruction small
bowel
caused
a high-grade
dilatation
of proximal
an
During this time, she had abdominal gastrointestinal
she
gastritis,
had
upper
hospital.
showed
a stricture
obstruction loops
Plain
abdominal
of the small bowel.
(Fig.
in the
in the small 1 A).
seendos-
for which
she was
persisted, radiographs
Barium examination mid
jejunum,
bowel
with
No abscess
or any
which
moderate other
mass
Received May 15, 1991; accepted after revision July 23, 1991. 1 Department of Diagnostic Imaging and Radiology, Children’s National requests to E. Shalaby-Aana. 2 Department of Surgery, Children’s National Medical Center, Washington, 3
Department
of Gastroenterology
4
Department
of Pathology,
AJR 158:63-64,
January
and Nutrition,
Children’s
National
1992 0361-803x/92/1
Children’s Medical 581 -0063
National
Center,
Medical
-
.
Kapur4
chronic
inflammation
and
with no mesenteric
had
no abnormal
Center,
1 1 1 Michigan
Ave.,
DC 20010.
Medical
Washington,
© American
.‘
signs
fibrosis.
The
adjacent
defect. At follow-up
mesentery
was
3 months later, the
or symptoms.
During a motor vehicle accident, a lap belt may cause blunt trauma to the abdomen, with contusion or perforation of the bowel and a hematoma in the mesentery [1 ]. Mechanisms of injury include crushing of the intestine between the vertebrae and the anterior abdominal wall, sudden increase in intraluminal pressure, and tangential tears at relatively fixed points along the bowel [2]. Most patients who have these injuries have signs and symptoms immediately after the accident. However, signs and symptoms due to an intestinal stricture occur a few weeks later. Stricture of the intestine after blunt abdominal trauma has been described [3, 4]; however, stricture associated specifically with lap belts has rarely been reported [3, 5, 6]. The pathophysiology of stricture formation due to trauma is probably ischemia of the bowel caused by mesenteric injury [3, 4]. lschemia leads to infarction of the affected segment, which then heals by fibrosis, with subsequent narrowing of the lumen. Hematoma or perforation of the bowel may also compromise blood supply and result in stricture. This was
CT scan of the brain but 1 week after the accident, on
.:
Discussion
abdominal
admitted
Sudesh
patient
she had no abdominal
on
patient
findings
vomiting
was
Four weeks after the injury, signs and symptoms
she
showed
findings
belt
Although
She was discharged,
continued all the
belt.
headache;
of bilious
ries;
was
seat
episodes raphy,
a lap
in an accident.
, .y
Injury
thickened
Case Report A
.
was seen on CT scans. A laparotomy was performed, with resection of a segment of stenotic jejunum (Fig. 1 B). Recovery was uneventful. Pathologic examination of the jejunum showed a stricture with trans-
In motor vehicle accidents, the lap-type seat belt can result in blunt trauma to the abdomen. The prevalence of intestinal injury has increased with the use of lap-belt restraints, and these injuries are usually apparent immediately. We describe a child with a lap-belt injury that resulted in intestinal stricture, which was manifested in a delayed fashion as partial smallbowel obstruction. This complication should be considered whenever a child who is restrained by a lap belt during a motor vehicle accident is injured.
automobile
and
.
.
Roentgen
Center,
Washington,
DC 20010. Ray Society
DC 20010.
NW.,
Washington,
DC 2001 0. Address
reprint
Downloaded from www.ajronline.org by 75.99.193.211 on 11/03/15 from IP address 75.99.193.211. Copyright ARRS. For personal use only; all rights reserved
64
SHALABY-RANA
Fig. 1.-13-year-old girl with lap-belt injury. A, Small-bowel barium examination shows a narrow stricture dilatation (arrowheads). B, Gross specimen of small bowel shows a fibrotic stricture longitudinally.
ET
AL.
AJA:158,
January
1992
2.-5-year-old boy with lap-belt injury. barium examination shows stricture in ileum (arrowheads) with proximal dilatation (solid arrow) and normal-caliber bowel distally (open arrows). Fig.
in jejunum (arrows).
most likely the case in a second child we saw recently in whom an ileal stricture developed after a lap-belt injury in a motor vehicle accident (Fig. 2). During surgery, a perforation was seen in a stenotic segment of intestine. Pathologic examination showed the perforation and mucosal ulceration, inflammation, and transmural fibrosis. Barium studies in two reported cases of an intestinal stricture caused by blunt abdominal trauma showed irregular mucosal folds and ulcerations, simulating Crohn disease [5, 6]. In both our cases, the possibility of inflammatory bowel disease was excluded by the absence of granulomatous inflammation. In addition, no evidence was seen of a primary vasculitis as the cause of the stricture.
(arrows) Bowel
with proximal
has been opened
Small-bowel
REFERENCES 1 . Dauterive AH, Flancbaum L, Cox EF. Blunt intestinal trauma: a modern day review. Ann Surg 1985;201 :198-203 2. Denis A, Allard M, Atlas H, Farkouh E. Changing trends with abdominal injury in seatbelt wearers. J Trauma 1983:23:1007-1008 3. Bryner U, Longerbeam J, Reeves C. Posttraumatic ischemic stenosis of the small bowel. Arch Surg 1980;1 15:1039-1 041 4. Lien G, Mon M, Enjoji M. Delayed posttraumatic ischemic stricture of the small intestine: a clinicopathologic study of four cases. Acta Pathol Jpn 1987;37: 1367-1 374 5. Taylor F. Seatbelt injury resulting in regional enteritis and intestinal obstruction.JAMA 1971:215:1154-1155 6. Taylor D, Magee F, Stordy 5, Chan N. Small bowel injury simulating Crohn’s disease after blunt abdominal trauma. J Clin Gastroenterol 1987:9:99-1 01
63
Case Report .
:
.
Intestinal Eglal
Stricture
Shalaby-Rana,1
Martin
Due to Lap-Belt
Eichelberger,2
Benny
Kerzner,3
mural
1 3-year-old
pain,
a band
wall
at the
hospital
girl
wearing
involved
of ecchymosis
level
of the
because
were normal.
of
for 3 weeks.
hepatobiliary
copy,
which
treated. and of
the
present The
showed
and
a passenger
in
the
anterior
was
was
seen
to another
a
occurred,
which
sonog-
scintigraphy, were
abdominal
pain
and an upper
normal.
possible
In addition,
bile reflux
at our
partial obstruction small
bowel
caused
a high-grade
dilatation
of proximal
an
During this time, she had abdominal gastrointestinal
she
gastritis,
had
upper
hospital.
showed
a stricture
obstruction loops
Plain
abdominal
of the small bowel.
(Fig.
in the
in the small 1 A).
seendos-
for which
she was
persisted, radiographs
Barium examination mid
jejunum,
bowel
with
No abscess
or any
which
moderate other
mass
Received May 15, 1991; accepted after revision July 23, 1991. 1 Department of Diagnostic Imaging and Radiology, Children’s National requests to E. Shalaby-Aana. 2 Department of Surgery, Children’s National Medical Center, Washington, 3
Department
of Gastroenterology
4
Department
of Pathology,
AJR 158:63-64,
January
and Nutrition,
Children’s
National
1992 0361-803x/92/1
Children’s Medical 581 -0063
National
Center,
Medical
-
.
Kapur4
chronic
inflammation
and
with no mesenteric
had
no abnormal
Center,
1 1 1 Michigan
Ave.,
DC 20010.
Medical
Washington,
© American
.‘
signs
fibrosis.
The
adjacent
defect. At follow-up
mesentery
was
3 months later, the
or symptoms.
During a motor vehicle accident, a lap belt may cause blunt trauma to the abdomen, with contusion or perforation of the bowel and a hematoma in the mesentery [1 ]. Mechanisms of injury include crushing of the intestine between the vertebrae and the anterior abdominal wall, sudden increase in intraluminal pressure, and tangential tears at relatively fixed points along the bowel [2]. Most patients who have these injuries have signs and symptoms immediately after the accident. However, signs and symptoms due to an intestinal stricture occur a few weeks later. Stricture of the intestine after blunt abdominal trauma has been described [3, 4]; however, stricture associated specifically with lap belts has rarely been reported [3, 5, 6]. The pathophysiology of stricture formation due to trauma is probably ischemia of the bowel caused by mesenteric injury [3, 4]. lschemia leads to infarction of the affected segment, which then heals by fibrosis, with subsequent narrowing of the lumen. Hematoma or perforation of the bowel may also compromise blood supply and result in stricture. This was
CT scan of the brain but 1 week after the accident, on
.:
Discussion
abdominal
admitted
Sudesh
patient
she had no abdominal
on
patient
findings
vomiting
was
Four weeks after the injury, signs and symptoms
she
showed
findings
belt
Although
She was discharged,
continued all the
belt.
headache;
of bilious
ries;
was
seat
episodes raphy,
a lap
in an accident.
, .y
Injury
thickened
Case Report A
.
was seen on CT scans. A laparotomy was performed, with resection of a segment of stenotic jejunum (Fig. 1 B). Recovery was uneventful. Pathologic examination of the jejunum showed a stricture with trans-
In motor vehicle accidents, the lap-type seat belt can result in blunt trauma to the abdomen. The prevalence of intestinal injury has increased with the use of lap-belt restraints, and these injuries are usually apparent immediately. We describe a child with a lap-belt injury that resulted in intestinal stricture, which was manifested in a delayed fashion as partial smallbowel obstruction. This complication should be considered whenever a child who is restrained by a lap belt during a motor vehicle accident is injured.
automobile
and
.
.
Roentgen
Center,
Washington,
DC 20010. Ray Society
DC 20010.
NW.,
Washington,
DC 2001 0. Address
reprint
Downloaded from www.ajronline.org by 75.99.193.211 on 11/03/15 from IP address 75.99.193.211. Copyright ARRS. For personal use only; all rights reserved
64
SHALABY-RANA
Fig. 1.-13-year-old girl with lap-belt injury. A, Small-bowel barium examination shows a narrow stricture dilatation (arrowheads). B, Gross specimen of small bowel shows a fibrotic stricture longitudinally.
ET
AL.
AJA:158,
January
1992
2.-5-year-old boy with lap-belt injury. barium examination shows stricture in ileum (arrowheads) with proximal dilatation (solid arrow) and normal-caliber bowel distally (open arrows). Fig.
in jejunum (arrows).
most likely the case in a second child we saw recently in whom an ileal stricture developed after a lap-belt injury in a motor vehicle accident (Fig. 2). During surgery, a perforation was seen in a stenotic segment of intestine. Pathologic examination showed the perforation and mucosal ulceration, inflammation, and transmural fibrosis. Barium studies in two reported cases of an intestinal stricture caused by blunt abdominal trauma showed irregular mucosal folds and ulcerations, simulating Crohn disease [5, 6]. In both our cases, the possibility of inflammatory bowel disease was excluded by the absence of granulomatous inflammation. In addition, no evidence was seen of a primary vasculitis as the cause of the stricture.
(arrows) Bowel
with proximal
has been opened
Small-bowel
REFERENCES 1 . Dauterive AH, Flancbaum L, Cox EF. Blunt intestinal trauma: a modern day review. Ann Surg 1985;201 :198-203 2. Denis A, Allard M, Atlas H, Farkouh E. Changing trends with abdominal injury in seatbelt wearers. J Trauma 1983:23:1007-1008 3. Bryner U, Longerbeam J, Reeves C. Posttraumatic ischemic stenosis of the small bowel. Arch Surg 1980;1 15:1039-1 041 4. Lien G, Mon M, Enjoji M. Delayed posttraumatic ischemic stricture of the small intestine: a clinicopathologic study of four cases. Acta Pathol Jpn 1987;37: 1367-1 374 5. Taylor F. Seatbelt injury resulting in regional enteritis and intestinal obstruction.JAMA 1971:215:1154-1155 6. Taylor D, Magee F, Stordy 5, Chan N. Small bowel injury simulating Crohn’s disease after blunt abdominal trauma. J Clin Gastroenterol 1987:9:99-1 01
